Provider Demographics
NPI:1174292767
Name:WOLDESILASSE, ZEYERUSALEM
Entity Type:Individual
Prefix:
First Name:ZEYERUSALEM
Middle Name:
Last Name:WOLDESILASSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 NECTAR CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-4333
Mailing Address - Country:US
Mailing Address - Phone:602-570-4281
Mailing Address - Fax:
Practice Address - Street 1:10385 OLD PLACERVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2506
Practice Address - Country:US
Practice Address - Phone:916-448-1770
Practice Address - Fax:916-448-3015
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95016910363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95016910Medicaid